The MD Anderson Cancer Center doctor gave the nursing team explicit orders to be kept in the loop if the vital signs of a new patient receiving chemotherapy hit specific thresholds.

A month later, in mid-August, the patient’s medical records showed such changes, breathing rates and blood pressure that had climbed to dangerous levels. In the span of just 11 hours, between early afternoon and not long after midnight, nurses recorded six such readings.

Not once did they communicate the change to the doctor. Three days later, the patient became unresponsive and died.

The event, buried in a Centers for Medicare & Medicaid Services report on MD Anderson released late last month, was startling not just because it represented the second potentially preventable death to come to light at the elite Houston cancer center. It was also startling because it showed the toll exacted, not just at MD Anderson but around the nation, by an unexpected group: overwhelmed nurses.

Harm from medical errors is nothing new — studies estimate between 210,000 and 440,000 Americans die annually from health-care provider mistakes, the nation’s third leading cause of death — but most people probably associate the bulk of the fatalities with doctors, the frequent target of medical malpractice lawsuits.

In reality, say experts, the clinicians most likely to be involved are nurses, who must straddle a thin line between doing no harm and doing the impossible.

“Nurses are the primary sentinels of patient care, the clinicians in at the bedside 24 hours a day, seven days a week,” said Christopher Friese, a University of Michigan professor of nursing and director of its Center for Improving Patient and Population Health. “They’re the ones in position to identify a problem and intervene and the ones under pressure to not make a mistake as patient volumes get higher and higher and cases get more and more complex.”

The burden is highly apparent in the CMS report, which devotes 268 pages to the deficiencies inspectors uncovered during an inspection of MD Anderson in August. Many of the shortcomings involved nursing services, shortcomings ranging from a failure to wash hands and deploy clean gloves to the improper clean-up of chemotherapy spills and an inadequate monitoring of vital signs of patients getting blood transfusions.

Such inadequate monitoring was also cited in a June CMS report undertaken after a transfusion with what turned out to be contaminated blood resulted in a death last December.

There are no numbers on the percentage of error-caused deaths that involve nurses, but safety experts acknowledge it’s likely high. Nurses are the largest piece of the U.S. healthcare workforce, numbering 4 million, compared to less than 1 million doctors. Nurses annually administer 18 million chemotherapy treatments, for instance, the most dangerous of medical interventions.

Understaffing is the biggest reason for the errors, nurse advocates say. It began in the 1990s, when managed care organizations called for squeezing out inefficiencies and institutions responded by laying off so-called “expensive” bedside caregivers.

“All the things necessary when people are acutely ill in a hospital have become less valued,” said Gerard Brogan, director of nursing practices for National Nurses United, the nation’s largest organization of registered nurses. “You cannot bill for tender-loving care, you cannot bill for psychological support, you cannot bill for spiritual succor.”

Patient-to-nurse ratios

Nurse understaffing in 2004 prompted California to pass a law requiring specific patient-to-nurse ratios, such as no more than two patients for every registered nurse in intensive care and critical care units. Brogan said Texas nurses tell him it’s not uncommon for them to take care of up to five ICU patients.

Though studies have documented the law’s benefits — one found that if New Jersey and Pennsylvania matched California’s ratios, they would have recorded 13.9 percent and 10.6 percent fewer deaths, respectively — no other state since has passed a similar law.

Nurse understaffing at MD Anderson was one of the shortcomings cited in the CMS report. It quoted a nurse calling staffing “a roller coaster,” fretting after she goes home about whether she missed anything with a patient or forgot to carry out an order, and acknowledging that “nurses learn how to do short cuts to take care of patients.”

The report concluded that MD Anderson’s inadequate number of licensed registered nurses “to provide care to all patients to meet their needs” resulted in “an inability to provide care ordered for the patient.”

MD Anderson will add more than 150 nurses this fiscal year, said a spokeswoman for the cancer center. The additions were planned before the CMS inspection.

‘Depleted, exhausted nurses’

Understaffing of nurses nationally has led to burnout well documented in studies. According to a National Academy of Medicine report published last month, 35 percent to 45 percent of nurses report substantial symptoms of burnout, defined as exhaustion, negativity and reduced professional effectiveness. The report said such clinicians are at least two times as likely to report they’ve made a major medical error in the last three months as those not suffering from burnout.

“Time pressures and the lack of resources have created an environment where errors are more likely,” said Cynda Rushton, a professor of clinical ethics at the Johns Hopkins School of Nursing and NAM report committee member. “Depleted, exhausted nurses are not as likely to have the focus and attention needed.”

Nurses in particular take a dim view of the conditions. Nearly 30 percent of about 13,00 nurses surveyed at hospitals in California, New Jersey, Florida and Pennsylvania in 2018 rated patient safety at their facilities as “unfavorable.” Fifty-five percent said they “wouldn’t definitely recommend their hospital, 37 percent said “important information is lost” during shift changes, 42 percent said “things fall between the cracks;” and 37 percent said staff “don’t feel free to question authority.”

Safety issues affect not just patients but nurses and other staffers. Michigan’s Friese says the greatest risk from poor clean-up of chemotherapy spills, such as those documented in the CMS report on MD Anderson, is staffers exposed throughout their shifts. Friese studied 12 top cancer centers and found all struggled to follow accepted guidance.

Experts hail CMS inspections because they require institutions to put in place plans of corrective action so they can prevent errors rather than respond to them. They say errors are generally the result of systemic problems, not personnel issues.

To that end, MD Anderson’s corrective plan, detailed in a 141-page letter to CMS, emphasizes increased training, more often than not for nurses. It includes educating nursing staff about policy updates from wound care to pain management to care planning; re-educating and testing their competence with electronic health records; and re-inforcing policy on the management of chemotherapy spills. The plan also calls for the adoption of a policy to promote the real-time adjustment of nurse staffing on specific units.

“That CMS report shows how very fragile health-care safety remains,” said Friese. “If a flagship cancer center like MD Anderson is having these problems, imagine the issues other centers across the country that don’t have their resources are having.”

Todd Ackerman is a veteran reporter who has covered medicine for the Houston Chronicle since 2001. A graduate of the University of California at Los Angeles, he previously worked for the Raleigh News & Observer, the National Catholic Register, the Los Angeles Downtown News and the San Clemente Sun-Post.